- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $245.47 / $446.68
| Professional | | $151.36 | $245.47 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $467.74 / $851.14
| Professional | | $288.40 | $467.74 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $602.56 / $1,096.48
| Professional | | $331.13 | $602.56 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $562.34 / $1,023.29
| Professional | | $346.74 | $562.34 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.47 / $512.86 / $1,445.44
| Professional | | $245.47 | $512.86 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.98 / $371.54 / $776.25
| Professional | | $194.98 | $371.54 | $776.25 |